1 / 33

Managing Hypertensive Crises: Diagnosis & Treatment Options

Learn about hypertensive crises, their diagnosis, and treatment with detailed insights on different medications and management approaches.

csmalls
Download Presentation

Managing Hypertensive Crises: Diagnosis & Treatment Options

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Hypertensive Crises Diagnosis and Treatment

  2. Hypertensive Crises • Severely elevated(BP>220/130mmhg) blood pressure with signs and symptoms of acute end organ damage • Requires hospitalization • Requires parenteral medication

  3. Hypertensive Urgency • Severely elevated blood pressure(BP>=220/130 mmhg) without signs and symptoms of acute end organ damage • Can be managed as an outpatient • Can be managed with short acting oral medications

  4. Severe Hypertension • BP 180/110 to 220/130 without symptoms or acute organ damage • Almost always occur in chronic HTN patients who stop their medication • Treat with long acting oral drugs

  5. Hypertensive Crises CNS - encephalopathy, intracranial hemorrhage, Grade 3-4 retinopathy Heart - CHF, MI, angina • Damage Kidneys - acute kidney injury, microscopic hematuria Vasculature - aortic dissection, eclampsia Vasculature

  6. Epidemiology • Hypertensive emergencies are common • Occur in 1-2% of the hypertensive population • But, 50 million hypertensive Americans • 500,000 hypertensive emergencies/year • Higher in the elderly • Incidence in men 2 times higher than in women

  7. Initial Evaluation • Assess for end-organ damage • Vascular Disease • Assess pulses in all extremities • Auscultate over renal arteries for bruits • Cardiopulmonary • Listen for rales (CHF) • Murmurs or gallops

  8. Initial Evaluation • Neurologic Exam • Hypertensive Encephalopathy - mental status changes, nausea, vomiting, seizures • Lateralizing signs uncommon and suggest cerebrovascular accident • Retinal Exam

  9. Retinopathy Grading • Grade 1 • Mild narrowing of the arterioles • “Copper Wire” • Grade 2 • Moderate narrowing - Copper wire and AV nicking

  10. Retinopathy Grading • Grade 3 • Severe Narrowing - Silver wire changes, hemorrhage, cotton wool spots, hard exudates • Grade 4 • Grade 3 + Papilledema • Grade 3 and 4 highly correlated with progression to end organ damage and decreased survival

  11. Normal

  12. Grade 1

  13. Grade 3 Retinopathy

  14. Lab Testing • ECG • LVH, look for signs of ischemia, injury, infarct • Renal Function Tests (urine included) • Elevated BUN, Creatinine, proteinuria, hematuria • CBC • CXR - pulmonary edema, aortic arch, cardiac enlargement

  15. Lab Testing • Aortic Dissection? • Suspect with severe tearing chest pain, unequal pulses, widened mediastinum • Contrast Chest CT Scan or MRI • Pulmonary Edema/CHF • Transthoracic Echocardiogram

  16. Cerebral Blood Flow Autoregulation • Cerebral Blood Flow Autoregulation • Cerebral Blood constant in normotensive individuals over range of MAPs of 60 -120 mm Hg. • In chronically hypertensive patients autoregulatory range is higher • MAP Range 100-120 to 150-160 mm Hg • Autoregulation also impaired in the elderly and those with cerebrovascular disease

  17. Management • Hypertensive Crises(elevated BP with target organ damage) • Parenteral meds • Goal - Reduce diastolic BP by 10-15% or to 110 mm Hg over a period of 30 - 60 minutes

  18. Management • Where? • ICU with close monitoring • Severe requires intra-arterial BP monitoring • Which Parenteral meds? • Depends on the situation

  19. Sodium nitroprusside • Disadvantages of sodium nitroprusside • Decrease cerebral blood flow and increases intracranial pressure • Can reduce regional blood flow in coronary artery disease • Risk of cyanide toxicity • Use when other agents not effective • Monitor thiocyanate levels • Avoid in renal or hepatic dysfunction • Choice in Aortic Dissection,CHF • 0.3-10 microgm/kg/min

  20. Urapidil • New central sympatholytic drug • Selective alpha -1 receptor blocks • Dose12.5-25 mg /kg bolus and 5-40 mg/hr iv infusion • Choice in HTN after CABG&After craniotomy

  21. Labetalol • Alpha&Beta Blocker(Beta>Alpha) • Choice in Hypertensive encephalopathy,Ischemic&Hemorrhagic Stroke,Severe preeclampsia/eclampsia,Aortic Dissection • 2-4 mg/min

  22. Management • HTN crises with advanced retinopathy without reduction of consciousness(labetalol,nitroprusside,urapidil,nicardipine) • HTN crises with encephalopathyBrain edema(posterior region)+ reduce of consciousness(10% reduction of BP in first hour and 15% in next 12 hours to 160/110

  23. Management • HTN crises with acute or hemorrhagic stroke • With thrombolytic therapyBP <185/110 • Without thrombolytic therapy15% reduction in BP • In hemorrhagic strokeSBP<180 • Urapidil,nicardipine,labetalol • Avoid of nitroprusside ,hydralazine

  24. Management • Acute coronary syndrome • TNG +IV motoral or esmolol • Labetalol or urapidil • Nitroprusside is cotraindicated • Acute heart failure Nitroprusside is choice(+Lasix)

  25. Management • Adernergic crisis(pheochromocytomaphentolamine+beta blocker or nitroprusside ,urapidil • Clonidine withdrawal clonidine • Cocaine or methamphetamine- induced HTN benzodiazepine +phentolamine

  26. Aortic Dissection • Standard therapy • Beta-adrenergic blocker plus vasodilator • Esmolol + Nicardipine • Nitroprusside can be used as well

  27. Management • Elevated BP without target organ damage • Hypertensive urgency • Oral meds • Goal - gradual reduction of BP over 24 - 48 hours

  28. Thank you!Questions?

More Related